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Stanley A.J.,University of New South Wales | Hasan I.,Ingham Institute | Crockett A.J.,University of South Australia | Crockett A.J.,University of Adelaide | And 2 more authors.
npj Primary Care Respiratory Medicine | Year: 2014

Background: Using the COPD Diagnostic Questionnaire (CDQ) as a selection tool for spirometry could potentially improve the efficiency and accuracy of chronic obstructive pulmonary disease (COPD) diagnosis in at-risk patients. Aim: To identify an optimal single cut point for the CDQ that divides primary care patients into low or high likelihood of COPD, with the latter group undergoing spirometry. Methods: Former or current smokers aged 40-85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse at various general practices in Sydney, Australia. The CDQ was collected and pre- and post-bronchodilator spirometry was performed. Cases with complete CDQ data and spirometry meeting quality standards were analysed (1,054 out of 1,631 patients). CDQ cut points were selected from a receiver operating characteristic (ROC) curve. Results: The area under the ROC curve was 0.713. A cut point of 19.5 had the optimal combination of sensitivity (63%) and specificity (70%) with two-thirds below this cut point. A cut point of 14.5 corresponded to a sensitivity of 91%, specificity of 35% and negative predictive value of 96%, and 31% of patients below this cut point. Conclusions: The CDQ can be used to select patients at risk of COPD for spirometry using one cut point. We consider two possible cut points. The 19.5 cut point excludes a higher proportion of patients from undergoing spirometry with the trade-off of more false negatives. The 14.5 cut point has a high sensitivity and negative predictive value, includes more potential COPD cases but has a higher rate of false positives. © 2014 Primary Care Respiratory Society UK/Macmillan Publishers Limited.


Arumugam S.,Ingham Institute | Jameson M.G.,Ingham Institute | Jameson M.G.,University of Wollongong | Xing A.,Ingham Institute | And 4 more authors.
Medical Physics | Year: 2013

Purpose: Image guided radiotherapy (IGRT) using cone beam computed tomography (CBCT) images greatly reduces interfractional patient positional uncertainties. An understanding of uncertainties in the IGRT process itself is essential to ensure appropriate use of this technology. The purpose of this study was to develop a phantom capable of assessing the accuracy of IGRT hardware and software including a 6 degrees of freedom patient positioning system and to investigate the accuracy of the Elekta XVI system in combination with the HexaPOD robotic treatment couch top. Methods: The constructed phantom enabled verification of the three automatic rigid body registrations (gray value, bone, seed) available in the Elekta XVI software and includes an adjustable mount that introduces known rotational offsets to the phantom from its reference position. Repeated positioning of the phantom was undertaken to assess phantom rotational accuracy. Using this phantom the accuracy of the XVI registration algorithms was assessed considering CBCT hardware factors and image resolution together with the residual error in the overall image guidance process when positional corrections were performed through the HexaPOD couch system. Results: The phantom positioning was found to be within 0.04 (σ = 0.12)°, 0.02 (σ = 0.13)°, and -0.03 (σ = 0.06)° in X, Y, and Z directions, respectively, enabling assessment of IGRT with a 6 degrees of freedom patient positioning system. The gray value registration algorithm showed the least error in calculated offsets with maximum mean difference of -0.2(σ = 0.4) mm in translational and -0.1(σ = 0.1)° in rotational directions for all image resolutions. Bone and seed registration were found to be sensitive to CBCT image resolution. Seed registration was found to be most sensitive demonstrating a maximum mean error of -0.3(σ = 0.9) mm and -1.4(σ = 1.7)° in translational and rotational directions over low resolution images, and this is reduced to -0.1(σ = 0.2) mm and -0.1(σ = 0.79)° using high resolution images. Conclusions: The phantom, capable of rotating independently about three orthogonal axes was successfully used to assess the accuracy of an IGRT system considering 6 degrees of freedom. The overall residual error in the image guidance process of XVI in combination with the HexaPOD couch was demonstrated to be less than 0.3 mm and 0.3° in translational and rotational directions when using the gray value registration with high resolution CBCT images. However, the residual error, especially in rotational directions, may increase when the seed registration is used with low resolution images. © 2013 American Association of Physicists in Medicine.


Eapen V.,University of New South Wales | Eapen V.,Ingham Institute | Snedden C.,University of New South Wales | Crncec R.,University of New South Wales | And 4 more authors.
Australian and New Zealand Journal of Psychiatry | Year: 2016

Objective: Tourette syndrome is often associated with attention deficit hyperactivity disorder, obsessive compulsive disorder and other co-morbidities, the presence of which can reduce health-related quality of life. The relationship between the number and type of co-morbidities and tic severity upon health-related quality of life has been insufficiently examined in Tourette syndrome populations and not at all in the Australian context. We hypothesised that an increased number of co-morbid diagnoses would be inversely related to health-related quality of life and that the presence of attention deficit hyperactivity disorder and obsessive compulsive disorder in particular would negatively impact health-related quality of life. Method: In all, 83 people with a previously established diagnosis of Tourette syndrome, who responded to a letter of invitation sent to the Tourette Syndrome Association of Australia past-member database, formed the study sample. Participants completed the Gilles de la Tourette Syndrome-Quality of Life Scale and a short form of the National Hospital Interview Schedule to assess tics and related behaviours. Results: Participants with pure-Tourette syndrome had significantly better health-related quality of life than those with Tourette syndrome and three or more co-morbid diagnoses. Few differences were observed between the pure-Tourette syndrome and Tourette syndrome and one or two co-morbid diagnoses groups. Analysis of the impact of individual co-morbid disorders and Tourette syndrome symptoms on health-related quality of life indicated that attention deficit hyperactivity disorder exerted a significant negative effect, as did the presence of complex tics, especially coprolalia and copropraxia. When these variables were examined in multiple regression analysis, number of co-morbidities and the presence of coprophenomena emerged as significant predictors of health-related quality of life. Conclusion: While tics are the defining feature of Tourette syndrome, it appears to be the presence of co-morbidities, attention deficit hyperactivity disorder, in particular, and coprophenomena that have the greater impact on health-related quality of life. This has implications for symptom-targeting in the treatment of Tourette syndrome since all available treatments are symptomatic and not disease modifying. © The Royal Australian and New Zealand College of Psychiatrists 2015.


Johnson M.,University of Western Sydney | Schmeid V.,University of Western Sydney | Lupton S.J.,University of Western Sydney | Austin M.-P.,University of New South Wales | And 6 more authors.
Archives of Women's Mental Health | Year: 2012

The purpose of this review was to critically analyse existing tools to measure perinatal mental health risk and report on the psychometric properties of the various approaches using defined criteria. An initial literature search revealed 379 papers, from which 21 papers relating to ten instruments were included in the final review. A further four papers were identified from experts (one excluded) in the field. The psychometric properties of six multidimensional tools and/or criteria were assessed. None of the instruments met all of the requirements of the psychometric properties defined. Some had used large sample sizes but reported low positive predictive values (Antenatal Risk Questionnaire (ANRQ)) or insufficient information regarding their clinical performance (Antenatal Routine Psychosocial Assessment (ARPA)), while others had insufficient sample sizes (Antenatal Psychosocial Health Assessment Tool, Camberwell Assessment of Need - Mothers and Contextual Assessment of Maternity Experience). The ANRQ has fulfilled the requirements of this analysis more comprehensively than any other instrument examined based on the defined rating criteria. While it is desirable to recommend a tool for clinical practice, it is important that clinicians are made aware of their limitations. The ANRQ and ARPA represent multidimensional instruments commonly used within Australia, developed within large samples with either cutoff scores or numbers of risk factors related to service outcomes. Clinicians can use these tools, within the limitations presented here, to determine the need for further intervention or to refer women to mental health services. However, the effectiveness of routine perinatal psychosocial assessment continues to be debated, with further research required. © The Author(s) 2012.


Eapen V.,University of New South Wales | Eapen V.,Ingham Institute | Robertson M.M.,University College London | Robertson M.M.,St Georges Hospital and Medical School
Neuropsychiatric Disease and Treatment | Year: 2015

This study addressed several questions relating to the core features of Tourette syndrome (TS) including in particular coprolalia (involuntary utterance of obscene words) and copropraxia (involuntary and inappropriate rude gesturing). A cohort of 400 TS patients was investigated. We observed that coprolalia occurred in 39% of the full cohort of 400 patients and copropraxia occurred in 20% of the cohort. Those with coprolalia had significantly higher Yale Global Tic Severity Scale (YGTSS) and Diagnostic Confidence Index (DCI) total scores and a significantly higher proportion also experienced copropraxia and echolalia. A subgroup of 222 TS patients with full comorbidity data available were also compared based on whether they had pure-TS (motor and vocal tics only) or associated comorbidities and co-existent psychopathologies (TS-plus). Pure-TS and TS-plus groups were compared across a number of characteristics including TS severity, associated clinical features, and family history. In this subgroup, 13.5% had pure-TS, while the remainder had comorbidities and psychopathologies consistent with TS-plus. Thirty-nine percent of the TS-plus group displayed coprolalia, compared to (0%) of the pure-TS group and the difference in proportions was statistically significant. The only other significant difference found between the two groups was that pure-TS was associated with no family history of obsessive compulsive disorder which is an interesting finding that may suggest that additional genes or environmental factors may be at play when TS is associated with comorbidities. Finally, differences between individuals with simple versus complex vocal/motor tics were evaluated. Results indicated that individuals with complex motor/vocal tics were significantly more likely to report premonitory urges/sensations than individuals with simple tics and TS. The implications of these findings for the assessment and understanding of TS are discussed. © 2015 Eapen and Robertson.


Leung M.,University of New South Wales | Wong V.W.,Ingham Institute | Hudson M.,Macquarie University | Hudson M.,University of Sydney | Leung D.Y.,University of New South Wales
Circulation: Cardiovascular Imaging | Year: 2016

Background-Patients with type 2 diabetes mellitus are at risk of heart failure. Specific therapeutic interventions for diabetic heart disease are still elusive. We aimed to examine the impact of improved glycemic control on left ventricular (LV) function in these patients. Methods and Results-A total of 105 subjects with type 2 diabetes mellitus (aged 54±10 years) and poor glycemic control received optimization of treatment for blood glucose, blood pressure, and cholesterol to recommended targets for 12 months. LV systolic and diastolic function, measured by LV global longitudinal strain (GLS) and septal e′ velocities, were compared before and after optimization. At baseline, patients had impaired LV systolic (GLS-14.9±3.2%) and diastolic function (e′ 6.2±1.7 cm/s). After 12 months, glycated hemoglobin (HbA1c) decreased from 10.3±2.4% to 8.3±2.0%, which was associated with significant relative improvement in GLS of 21% and septal e′ of 24%. There was a progressively greater improvement in GLS as patients achieved a lower final HbA1c. Patients achieving an HbA1c of <7.0% had the largest improvement. The 15 patients whose HbA1c worsened experienced a decline in GLS. Patients who improved their HbA1c by ≥1.0% had a significantly higher relative improvement in e′ than those who did not (32% versus 8%; P=0.003). Baseline GLS, decrease in body mass index, and treatment with metformin were additional independent predictors of GLS improvement. Conclusions-Improvements in glycemic control over a 12-month period led to improvements in LV systolic and diastolic function. This may have long-term prognostic implications. © 2016 American Heart Association, Inc.


Gattellari M.,University of New South Wales | Gattellari M.,Ingham Institute | Goumas C.,University of New South Wales | Biost F.G.M.,University of New South Wales | And 4 more authors.
Stroke | Year: 2012

Background and Purpose-: There is a lack of modern-day data quantifying the effect of transient ischemic attack (TIA) on survival, and recent data do not take into account expected survival. Methods-: Data for 22 157 adults hospitalized with a TIA from July 1, 2000, to June 30, 2007, in New South Wales, Australia, were linked with registered deaths to June 30, 2009. We estimated survival relative to the age-and sex-matched general population up to 9-years after hospitalization for TIA comparing relative risk of excess death between selected subgroups. Results-: At 1 year, 91.5% of hospitalized patients with TIA survived compared with 95.0% expected survival in the general population. After 5 years, observed survival was 13.2% lower than expected in relative terms. By 9 years, observed survival was 20% lower than expected. Females had higher relative survival than males (relative risk, 0.79; 95% CI, 0.69-0.90; P<0.001). Increasing age was associated with an increasing risk of excess death compared with the age-matched population. Prior hospitalization for stroke (relative risk, 2.63; 95% CI, 1.98-3.49) but not TIA (relative risk, 1.42; 95% CI, 0.86-2.35) significantly increased the risk of excess death. Of all risk factors assessed, congestive heart failure, atrial fibrillation, and prior hospitalization for stroke most strongly impacted survival. Conclusions-: This study is the first to quantify the long-term effect of hospitalized TIA on relative survival according to age, sex, and medical history. TIA reduces survival by 4% in the first year and by 20% within 9 years. TIA has a minimal effect on mortality in patients <50 years but heralds significant reduction in life expectancy in those >65 years. © 2011 American Heart Association. All rights reserved.


Thakkar V.,University of Western Sydney | Thakkar V.,University of New South Wales | Thakkar V.,Ingham Institute | Lau E.M.T.,University of Sydney
Best Practice and Research: Clinical Rheumatology | Year: 2016

Over the past two decades, there have been several advances in the assessment and management of connective tissue disease-related pulmonary arterial hypertension (CTD-PAH) that improved outcomes of the treatment of this lethal disease, and this will be the focus of this study. Systemic sclerosis is the leading cause of CTD-PAH, followed by systemic lupus erythematosus, mixed connective tissue disease, idiopathic inflammatory myositis, rheumatoid arthritis, and Sjogren's syndrome. Clinical registries have been invaluable in informing about the burden of disease, risk and prognostic factors, and temporal trends with respect to treatment and outcome in CTD-PAH. The major advances have centered on improved disease classification and diagnostic criteria, screening and early diagnosis, the emergence of evidence-based therapies including combination goal-orientated treatment strategies, and the establishment of centers with expertise in PAH. © 2016.


Gattellari M.,University of New South Wales | Gattellari M.,Ingham Institute | Goumas C.,University of New South Wales | Aitken R.,University of Newcastle | And 3 more authors.
Cerebrovascular Diseases | Year: 2011

Background: In the past decade the prevalence of atrial fibrillation (AF) has been increasing in ageing populations while stroke prevention and management have advanced. To inform clinician practice, health service planning and further research, it is timely to reassess the burden of AF-related ischaemic stroke. Methods: We identified patients aged 18+ years with a primary or stay diagnosis of ischaemic stroke (ICD-10-AM I63.x), from July 1, 2000 to June 30, 2006, using an administrative health dataset of all hospitalisations in New South Wales (population ∼7 million). Fact of death was determined to December 2007. Results: Of the 26,960 index cases of ischaemic stroke, 25.4% had AF recorded during admission. Median age for AF and non-AF patients was 80.4 and 75.2 years, respectively (p < 0.001). Mortality was significantly higher in patients with AF at 30 days (19.4 vs. 11.5%), 90 days (27.7 vs. 15.8%) and 365 days (38.5 vs. 22.6%) (p values <0.0001). Adjusting for age and co-morbidities reduced these differences, with 90-day mortality of 20.9% in AF patients versus 14.7% in non-AF patients (p value <0.0001). The effect of AF on outcomes appears stronger in younger stroke patients relative to patients without AF (p value interaction <0.0001). At 30 days, the relative risk of mortality due to AF was 3.16 (95% CI 1.92-5.25) amongst those younger than 50, 1.71 (95% CI 1.32-2.22) in patients aged 50-64 years, 1.39 (95% CI 1.16-1.66) in patients aged 65-74 years, 1.29 (95% CI 1.17-1.43) in those aged 75-84 years, and 1.23 (95% CI 1.13-1.33) in those aged 85+ years. AF patients, surviving admission, spent a median of 19.2 days (95% CI 18.4-20.1) in hospital compared with 14.5 days (95% CI 13.9-15.1) for patients without AF (p < 0.001), with differences in length of stay greatest in younger patients (p value interaction <0.0001). 90-Day stroke survivors with AF spent an average of 21.5 days (95% CI 20.6-22.4) in hospital versus 16.6 days (95% CI 15.9-17.2) in those without AF. AF patients accessed more in-hospital rehabilitation (36.6%; 95% CI 35.0-38.2) than patients without AF (31.8%; 95% CI 31.0-32.7) (p value <0.0001), and differences in the proportion of AF versus non-AF patients accessing rehabilitation was greatest in younger patients (p value interaction <0.0006). Conclusions: Ischaemicstroke patients with AF have substantially worse outcomes than patients without AF, which can be partly explained by older age and greater co-morbidities. We have quantified the large effect of AF in younger patients and our results strongly argue for new antithrombotic research in young AF patients. Copyright © 2011 S. Karger AG, Basel.


PubMed | University of Sydney, Stanford University, Illawarra Cancer Care Center and Ingham Institute
Type: Journal Article | Journal: Medical physics | Year: 2016

To test the functionality of medical electron guns within the fringe field of a purpose built superconducting MRI magnet, and to test different recovery techniques for a variety of imaging field strengths and SIDs.Three different electron guns were simulated using Finite Element Modelling; a standard diode gun, a standard triode gun, and a novel diode gun designed to operate within parallel magnetic fields. The approximate working regime of each gun was established by assessing exit current in constant magnetic fields of varying strength and defining working as less than 10% change in injection current. Next, the 1.0T MRI magnet was simulated within Comsol Multiphysics. The coil currents in this model were also scaled to produce field strengths of .5, 1, 1.5 and 3T. Various magnetic shield configurations were simulated, varying the SID from 800 to 1300mm. The average magnetic field within the gun region was assessed together with the distortion in the imaging volume - greater than 150uT distortion was considered unacceptable.The conventional guns functioned in fields of less than 7.5mT. Conversely, the redesigned diode required fields greater than .1T to function correctly. Magnetic shielding was feasible for SIDS of greater than 1000mm for field strengths of .5T and 1T, and 1100mm for 1.5 and 3.0T. Beyond these limits shielding resulted in unacceptable MRI distortion. In contrast, the redesigned diode could perform acceptably for SIDs of less than 812, 896, 931, and 974mm for imaging strengths of 0.5, 1.0, 1.5, 3.0T.For in-line MRIlinac configurations where the electron gun is operating in low field regions, shielding is a straight forward option. However, as magnetic field strength increases and the SID is reduced, shielding results in too great a distortion in the MRI and redesigning the electron optics is the preferable solution. The authors would like to acknowledge funding from the National Health and Research Council (AUS), National Institute of Health (NIH), and Cancer Institute NSW.

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